Comparative effectiveness of noninvasive ventilation interfaces in critically ill adults: A systematic review and Bayesian network meta-analysis

Abstract

Objectives: To systematically review the effectiveness of different types of interfaces in the treatment of critically ill patients with respiratory failure requiring NIV.

Methods: Parallel randomized controlled trials (RCTs) were identified through a search conducted in the MEDLINE, CENTRAL, EMBASE, and LILACS databases. Review Manager 5 software was used for direct comparisons. Risk ratios (RR) with 95% confidence interval (CI) or credible interval (CrI) were used for dichotomous outcomes. Continuous outcomes were reported as mean differences (MD) with 95% CIs. MetaInsight software was used for conducting network meta-analysis (NMA) with Bayesian random-effects models.

Results: A systematic search was conducted on August 4, 2022, and last updated on November 6, 2024. Seven studies were included, involving 406 patients, and four different interfaces (helmet, oronasal, nasal, and full-face) were utilized. Helmet may reduce intubation rate, ICU and hospital length of stay, when compared to oronasal mask (RR 0.38 [95% CrI 0.2 to 0.75], RR -3.34 [95% CrI -6.94 to 0.49] and RR -2.4 [95% CrI -6.23 to 1.62]), with low certainty of the evidence. Furthermore, the evidence is very uncertain regarding the effects of the helmet on reducing serious adverse events, with very low certainty of the evidence. The evidence remains uncertain for the outcomes of in-hospital mortality, serious adverse events, mild and moderate adverse events, comfort, and tolerance.

Conclusions: The helmet interface probably reduces the length of stay and intubation rates when used for non-invasive ventilation in critically ill patients with respiratory failure. However, the findings should be interpreted with caution as it generates from RCT with small sample sizes.

Implications for clinical practice: This network meta-analysis offers comparative evidence to guide clinical decision-making regarding interface selection during noninvasive ventilation, with the potential to enhance treatment effectiveness and patient outcomes.

Keywords: Meta-analysis; Networkmeta-analysis; Noninvasive ventilation; Positive-pressure respiration; Systematic review.